Elbow Instability [PDF]

Adam J. Seidl, MD Assistant Professor – University of Colorado School of Medicine Shoulder & Elbow Surgery Division of Sports Medicine and Shoulder Surgery Division of Hand, Wrist, and Elbow Surgery

  

Anatomy and Biomechanics Spectrum of Instability Acute Instability  Diagnosis  Management



Chronic Instability  Diagnosis  Management ▪ “Old School” ▪ State of the Art



Primary Stabilizers  Ulnohumeral

articulation  MCL complex  LCL complex 

Secondary Stabilizers  Radial head

 Capsule  Musculotendinous



Acute Elbow Instability  Simple Elbow Dislocation  Complex Elbow Dislocation



Chronic Elbow Instability  Posterolateral Rotatory Instability

 Valgus Elbow Instability



Simple vs. Complex Elbow Dislocation  Simple ▪ Elbow dislocation without associated fracture ▪ Primarily a capsuloligamentous / soft tissue injury ▪ Post reduction radiographs reveal periarticular fractures in up to 60% of cases and operative exploration reveals high rate of osteochondral injuries

 Complex ▪ Elbow dislocation with associated fracture





Anterior Posterior ~ 90%  Posterior  Posteromedial  Posterolateral



 

Medial Lateral Divergent



Initial Evaluation  Neurovascular examination  Check DRUJ for Essex-Lopresti injury



Reduction  Longitudinal traction, gentle flexion



Post reduction radiographs  Evaluate ulnohumeral radioulnar and radiocapitellar joints, fractures  “Drop sign” - widening of the ulnohumeral joint seen on the lateral radiograph  Represents a subtle resting subluxation - frequently resolves spontaneously



Post reduction management  sling and early ROM can be initiated  May need to splint for 1 week in position of support

   

56% of patients reported residual subjective stiffness of the elbow 8% reported subjective instability 62% reported residual pain The Satisfaction, DASH, and Oxford elbow scores showed good correlation with absolute range of motion in the injured elbow



Posterolateral Rotatory  ”Terrible Triad” ▪ Radial Head ▪ Coronoid ▪ Dislocation – ligaments/capsule



Posteromedial Rotatory  Anteromedial coronoid

 LUCL



Trans-olecranon



Surgical Approach  Lateral/Medial vs global posterior  If RHR – remove  Coronoid/ant capsule 1st  RH ORIF vs RHR 2nd

 LCL 3rd  Assess stability – unstable  MCL



Surgical Approach  Medial Approach ▪ Hotchkiss “over the top” -- small fractures ▪ Between FCU heads – involve sublime tubercle ▪ Elevate Entire FCU – very large fractures

 Lateral Approach ▪ LUCL Repair ▪ Protects fracture fixation ▪ Can be used in isolation in very small fractures



Surgical Approach  Posterior ▪ Work Through the Fracture

 Restore Ulnar length, alignment, rotation ▪ Greater Sigmoid Notch ▪ Coronoid Process



Posterolateral Rotatory Instability  Most common pattern

 Described by O’Driscoll 1991  Deficient LCL



Valgus Instability  Microtrauma from repetitive activity > dislocation

 Overhead athletes

 Diagnosis ▪ History often subtle ▪ Consider in refractory tennis elbow ▪ Exam – unremarkable without provocative tests ▪ PLRI Test ▪ Chair Sign

▪ Imaging ▪ MRI

 Treatment ▪ Open reconstruction of LUCL ▪ Kocher approach  Palmaris autograft vs allograft (semi-T)  Docking  Figure of 8  Interference Screw

▪ State of The Art -- Arthroscopic

 Diagnosis ▪ Anteromedial view during pivot shift ▪ Radial Head will translate posterior

▪ ”Drive-through sign” – insert video here

 Treatment ▪ Repair – Acute > Chroic ▪ Plication -- Chronic

 Technique ▪ Scope Proximal Posterolateral ▪ Sutures from distal to proximal ▪ Percutaneous suture retrieval and tying

 Results

 Diagnosis ▪ Far less common that PLRI ▪ Overhead throwing athletes ▪ History ▪ Pain > Instability sx ▪ Loss of velocity ▪ + Ulnar nerve symptoms

▪ Exam ▪ Milking maneuver ▪ Moving valgus stress

▪ Imaging -- MRI

 Surgical Treatment ▪ Reserved for high level thrower ▪ Technique – numerus ▪ Jobe ▪ ASMI modification ▪ HSS – Docking

▪ Cutting Edge ▪ Scope?

 Diagnosis ▪ Can be used to verify ▪ Anteromedial portal ▪ Elbow at 60 degrees with valgus stress  gapping

 Treatment ▪ Identify & address other pathology ▪ Osteophytes ▪ Loose bodies

▪ Anterior bundle of UCL hard to identify